Bromelain-based enzymatic burn debridement: Spanish multidisciplinary consensus.

Background: Bromelain-based enzymatic debridement is gaining increased interest from burn specialists in the last few years. The objective of this manuscript is to update the previous, first Spanish consensus document from 2017 (Martínez-Méndez et al. 43:193-202, 2017), on the use of enzymatic debridement with NexoBrid® in burn injuries, adding the clinical experience of a larger panel of experts, integrating plastic surgeons, intensivists, and anesthesiologists. Methods: A consensus guideline was established by following a modified Delphi methodology of a 38-topic survey in two rounds of participation. Items were grouped in six domains: general indication, indication in critical patients, pain management, conditions for NexoBrid® application, NexoBrid® application technique, and post-debridement wound care. Results: In the first round, experts established consensus (strongly agree or agree) on 13 of the 38 statements. After the second round, a consensus was reached on 24 of the 25 remaining statements (97.2%). Conclusions: The present updated consensus document provides recommendations on the use of bromelain-based enzymatic debridement NexoBrid®, integrating the extensive clinical experience of plastic surgeons, intensivists, and anesthesiologists in Spain. Further clinical trials and studies are required to corroborate, modify, or fine tune the current statements.

Labor humanitaria en África. Nuestra experiencia / Humanitarian work in Africa. Our experience

La tercera campaña de ayuda humanitaria llevada a cabo por la Sociedad Española de Cirugía Plástica, Reparadora y Estética (SECPRE) en Monrovia (Liberia) se desarrolló durante el mes de noviembre de 2018 y supone la continuación de este tipo de ayudas en el continente africano promovidas por la ONG Juan Ciudad. Como en otras misiones humanitarias protagonizadas por cirujanos plásticos, el objetivo es mejorar la calidad de vida de la población más vulnerable y colaborar en su reincorporación a la sociedad. Las campañas humanitarias quirúrgicas tienen una fecha de ida y otra de vuelta, con un proyecto de actividad quirúrgica que desarrollar en pocos días y en unas condiciones de recursos limitados. Una buena planificación, apoyándonos en los datos obtenidos de las experiencias anteriores, facilitó la consecución de nuestros objetivos. Con la presentación de este artículo queremos transmitir nuestra experiencia personal en este proyecto

The third humanitarian aid campaign by the Spanish Society of Plastic, Reconstructive and Aesthetic Surgery (SECPRE) in Monrovia (Liberia) was carried out in November 2018 and reflects the continuation of such aid programmes in the African continent promoted by the NGO Juan Ciudad. As in other humanitarian missions involving plastic surgeons, the objective is to improve the quality of life of the most vulnerable population and to collaborate in their reintegration into society. The surgical humanitarian campaigns have a round trip date, with a surgical activity project to be developed in a few days and under limited resource conditions. Good planning, based on the data obtained from previous experiences contributed to the achievement of our objectives. Our aim presenting this article is sharing our personal experience in this project

Sedoanalgesia para procedimientos de desbridamiento enzimático en pacientes con quemaduras en cara y cuello / Procedural sedation analgesia for enzymatic debridement in patients with burns on face and neck

Introducción y Objetivo: La cantidad de procedimientos mínimamente invasivos realizados fuera del quirófano ha crecido en las últimas décadas. La sedación, la analgesia o ambas, pueden ser necesarias para muchos de estos procedimientos de intervención o diagnóstico. Sin embargo, y hasta donde hemos podido conocer, no hay experiencia en el uso de sedoanalgesia para procedimientos (SAP) en pacientes con quemaduras faciales que necesitan desbridamiento enzimático El objetivo de este trabajo es evaluar la eficacia y la seguridad de la SAP para el control del dolor en pacientes con quemaduras faciales sometidos a tratamiento con desbridamiento enzimático. Material y Método: Describimos 16 casos de pacientes adultos con quemaduras en cara y cuello que necesitaron desbridamiento enzimático. Cuatro pacientes sin ventilación mecánica fueron tratados con SAP. Resultados: La SAP generalmente requiere combinación de múltiples agentes para alcanzar los efectos deseados de analgesia más ansiolisis. El procedimiento fue bien tolerado y los pacientes no sufrieron complicaciones. Conclusiones: Presentamos la SAP como opción para el desbridamiento enzimático de quemaduras faciales en pacientes adultos sin ventilación mecánica

Background and Objective: The number of minimally invasive procedures performed outside of the operating room has grown exponentially over the last several decades. Sedation, analgesia, or both may be needed for many of these interventional or diagnostic procedures. However, to our knowledge, there is no experience on the use of procedural sedation analgesia (PSA) in patients with facial burns who need enzymatic debridement. The aim of this study is to assess the effectiveness and safety of PSA for pain relief in patients with facial burns undergoing enzymatic debridement. Methods: We describe 16 cases of adult patients with burns on the face and neck who needed enzymatic debridement. Four patients without mechanical ventilation were treated with PSA. The procedure was well tolerated and the patients did not suffer complications. Results: PSA usually requires combinations of multiple agents to reach desired effects of analgesia plus anxiolysis. The procedure was well tolerated and the patients did not suffer complications. Conclusions: PSA can be an option for enzymatic debridement of facial burns in adults patients without mechanical ventilation

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Microbiology in burns patients with blood stream infections: trends over time and during the course of hospitalization.

BACKGROUND: Bloodstream infections (BSI) are a major cause of mortality in burns patients. Knowledge of the microbiology is crucial to direct empirical therapy. We sought to determine the causative microorganisms and antibiotic resistance in burns patients with BSI. METHODS: All consecutive BSI episodes in a tertiary hospital burns unit from 2000 to 2014 were included. The following three subperiods were compared: 2000-2004, 2005-2009 and 2010-2014. Changes in BSI occurring during early and late hospitalization periods were evaluated. RESULTS: A total of 103 BSI episodes were included. The cumulative incidence was 2.4 episodes/1000 patient days. A positive trend in the frequency of Gram-negative BSI, especially in the upsurge of Pseudomonas aeruginosa and Klebsiella spp. BSI after 2004, was observed. The most common causative pathogens in early BSI were Gram-positive microorganisms. P. aeruginosa and Klebsiella spp. became the predominant aetiology in the fourth week of hospitalization and beyond. There was a progressive increase in imipenem-resistant P. aeruginosa over time (0%, 67%, 75% in 2000-2004, 2005-2009, 2010-2014, respectively) and during the hospital stay (50% vs. 85.7%, in <7 days-BSI vs. >30 days-BSI, respectively). A higher SOFA (Sepsis-related Organ Failure Assessment) score was associated with Gram-negative BSI versus non-Gram-negative BSI (median: 2.5 vs. 0; p = 0.041). CONCLUSIONS: There is a changing trend in the types of pathogens causing BSI in burns patients over the 14-year period and during the course of hospitalization. The problematic increase in carbapenem-resistance highlights the need for new antimicrobial stewardship policies and antibiotic prescribing protocols.

Guía clínica de consenso en el uso de desbridamiento enzimático en quemaduras con NexoBrid(R) / Consensus guideline about the use of the enzymatic debridement in burn injuries with NexoBrid(R)

Introducción y Objetivo. El desbridamiento precoz es la base del tratamiento de las quemaduras. La retirada de la escara durante las primeras 72 horas es la mejor opción para reducir la estancia hospitalaria y los eventos infecciosos. Sin embargo, en muchas ocasiones se compromete la dermis viable necesaria para obtener los mejores resultados estéticos y funcionales, obligando a injertar el lecho. Hay numerosa evidencia acerca de la reducción de las tasas de injerto, la pérdida hemática y el número de intervenciones cuando se utiliza un desbridante enzimático, NexoBrid(R). El objetivo de esta publicación es establecer una guía clínica basada en la opinión de los expertos españoles. Material y Método. Se diseñó un panel de 7 expertos de las principales Unidades de Quemados españolas, con más de 350 pacientes tratados, que discutió las diferentes fases del tratamiento con NexoBrid(R) para obtener una guía clínica de consenso acerca de la indicación, uso y manejo del desbridamiento enzimático. Resultados. Se alcanzó un alto nivel de consenso, con más del 70% de acuerdo en cada una de las fases de tratamiento. Todos los aspectos del tratamiento con NexoBrid(R) fueron discutidos durante la reunión, así como las indicaciones y limitaciones de su uso, incluyendo todas las nuevas evidencias publicadas hasta el momento. También las diversas opciones utilizadas por los diferentes centros de quemados españoles, alcanzando una recomendación global sobre su uso. Conclusiones. Se redactó un documento como guía clínica preliminar sobre el uso de NexoBrid(R) hasta que se creen nuevas guías basadas en evidencia. No existe ningún otro consenso similar publicado hasta el momento (AU)

Background and Objective: Early debridement is considered the keystone of the burn injuries treatment. It is well known that the eschar removal during the first 72 hours is the best option to reduce the hospital stay and the infectious events. However this treatment compromise the preservation of viable dermis, needed to reach the best functional and aesthetic outcome, therefore grafting the wound bed is mandatory. There is increasing evidence that enzymatic debridement with NexoBrid(R) is showing a reduction in the grafting rate, the blood loss and the number of surgical excisions. The objective of this consensus meeting is providing guidelines based in Spanish experts experiences. Methods. A panel of 7 experts from the main Spanish Burn Units were design, with more than 350 patients treated by them, where the different statements were discussed, trying to get a consensus guideline of the indication, use and management of NexoBrid(R). Results. A high level agreement was stated. All the aspects of NexoBrid(R) treatment were discussed showing an agreement of 70%, as well as the indications and limitations of its use. All new evidence published so far this paper was included. Different treatment options used by the Spanish Burn Centers were discussed, showing a global recommendation in their use. Conclusions. A consensus document was created as a preliminary guideline for the NexoBrid(R) use until further guidelines are available. There is no other consensus guideline published so far this document (AU)

EHTIC study: Evaluation of a new hemostatic agent based on tissue factor in skin grafting procedures.

BACKGROUND: Excessive bleeding is a major concern in scar debridement and grafting procedures. TT-173 is a new topical hemostatic agent based on recombinant human tissue factor that has shown promising results in patients who underwent tooth extraction. EHTIC study sought to evaluate the efficacy and safety of TT-173 to reduce the bleeding in donor sites of skin grafting procedures. METHODS: EHTIC study was a phase II, randomized, parallel, double blind, placebo controlled trial. Patients received TT-173 (n=38) or placebo (n=33) sprayed over donor site after graft harvest. Time to hemostasis and incidence of adverse events were recorded. Systemic absorption of the product and its immunogenicity were also measured during the follow up of the subjects. RESULTS: Treatment with TT-173 significantly reduced the bleeding time from 7 to 3min (Log-Rank p<0.0001). Moreover, bleeding stopped within the 10min of evaluation period in all the patients that received TT-173. In contrast, 24.24% of patients from placebo group required additional measures to arrest hemorrhage (Fisher p=0.0013). Product related adverse events, systemic absorption into blood stream, interferences with the healing of the donor site or immunogenic reaction against TT-173 were not observed. CONCLUSION: The new hemostatic agent TT-173 has proven efficacious and safe to reduce the bleeding from donor site. This study paves the way for further investigation of the product as topical hemostatic treatment in plastic surgery and other surgical indications.